Basic Information
| Provider Information | |||||||||
| NPI: | 1235274804 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COLLEGE COMMUNITY SERVICES | ||||||||
| LastName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | AMHS CCS CAMINO NUEVO RECOVERY CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8337 TELEGRAPH RD STE 115 | ||||||||
| Address2: | |||||||||
| City: | PICO RIVERA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 906604940 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5624675440 | ||||||||
| FaxNumber: | 5624675553 | ||||||||
| Practice Location | |||||||||
| Address1: | 2001 E 4TH ST STE 200&205 | ||||||||
| Address2: | |||||||||
| City: | SANTA ANA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 927053916 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7148248144 | ||||||||
| FaxNumber: | 7148248141 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/21/2007 | ||||||||
| LastUpdateDate: | 08/09/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | GINTER | ||||||||
| AuthorizedOfficialFirstName: | TRACY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR OF STATE OPERATIONS | ||||||||
| AuthorizedOfficialTelephone: | 7145036880 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | CBCS | ||||||||
| NPICertificationDate: | 08/09/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 30DK | 01 | CA | MEDI-CAL PROVIDER NUMBER | OTHER |